In the News for the Week of 10-31-06
- Shingles vaccine recommended by advisory panel
- Campaign raises awareness of chronic fatigue syndrome
- Fewer Americans quitting smoking
- CT scans improve survival in lung cancer patients
- PIER rated best of evidence-based medicine tools
- ACP supports changes to Medicare consultation policy
- ACP resources available for young physician members
- ACP Journal Club: Prompt revascularization improves survival after STEMI and cardiogenic shock
A government advisory panel has recommended that all Americans age 60 or older be vaccinated against the herpes zoster virus, including those who have already had the virus. The Advisory Committee on Immunization Practices (ACIP) submitted the recommendation to the CDC on Oct. 25.
The first shingles vaccine (Merck's Zostavax) was approved by the FDA in May. Approval of the vaccine was based largely on a study of more than 38,000 people, in which 19,000 received the actual vaccine and the others were given placebo. After a follow-up period of three years, those who received the vaccine developed shingles at half the rate of the participants in the placebo group, said a Oct. 26 CDC news release. The vaccine also reduced post-herpetic neuralgia by 67%.
The vaccine's effectiveness declined with age, said the CDC, but the risk of chronic pain was lowered for those who were vaccinated but still developed shingles. The most common reported side effects were mild pain at the injection site and headache.
Some health insurers currently cover the single-dose vaccine, which costs about $150 per shot, said the Oct. 26 Washington Post, noting that the APIC's recommendation may drive more insurers to cover it. The CDC reports that there are about 1 million cases of shingles annually, with the risk highest among the elderly.
The CDC news release is online.
The Washington Post is online.
The CDC will launch a national awareness campaign on Nov. 3 aimed at increasing awareness of chronic fatigue syndrome (CFS) among the public and health care professionals.
An estimated 1 million people in the U.S. are affected by CFS and, of those, 80% have not been diagnosed and are not receiving proper medical care for their illness, the CDC said. The campaign will include national print advertising and public service announcements for TV and radio, as well as a traveling photo exhibit by photographer George Lange called “The Faces of Chronic Fatigue Syndrome.”
CDC officials expect that the campaign will drive more symptomatic individuals to their health care providers. To assist physicians in treating these patients, the CDC has set up a Web site with current information on best practices for CFS diagnosis and treatment. The site also provides easy-to-understand, downloadable educational tools for patients and their families.
More information about the campaign is online.
Two new studies reported that the percentage of smokers in the U.S. has leveled off after years of steady decline. The proportion of adults who smoke, at 20.9%, was the same in 2005 as in 2004, according to a survey released in last week’s CDC Mortality and Morbidity Weekly Report (MMWR).
Prior to the 2005 National Health Interview Survey, which interviewed 31,428 people age 18 and older, the smoking rate had dropped every year since 1997. A second study surveyed smoking habits by geographic area, finding variations from a high of 28.7% in Kentucky to a low of 11.5% in Utah.
Possible causes of the plateau in smoking cessation include states cutting back on anti-smoking programs, the price of cigarettes rising more slowly and increased advertising by tobacco companies, federal health officials said in the Oct. 27 Washington Post. The MMWR noted that the government's Healthy People 2010 campaign has a goal of reducing cigarette smoking to 12% by 2010.
In other smoking research, the Drug Policy Alliance, an advocacy group, released a poll that found 45% of Americans support making cigarettes illegal, while a study presented at the American College of Chest Physicians’ scientific assembly found that smokers who received nicotine replacement therapy (NRT) during their stay in an intensive care unit had a higher risk of death than smokers who did not receive NRT.
The CDC’s MMWR is online.
The Washington Post is online.
A newly published study found that annual spiral CT screening could detect clinical stage I lung cancer and improve the survival rate of patients. Researchers conducted a systematic case-control observational study of 31,567 asymptomatic people who were at risk for lung cancer.
CT screening resulted in a diagnosis of lung cancer in 484 participants, 85% of them with clinical stage I cancer. In contrast with the typical five-year survival rate of 70% in patients with clinical stage I cancer, study participants had an estimated 10-year survival rate of 88%. Among the 302 participants who underwent surgical resection within a month of diagnosis, the survival rate was 92%. The study was published in the Oct. 26 New England Journal of Medicine.
This study provides the first documentation of a detection test combined with planned management and long-term follow-up for lung cancer, noted an accompanying editorial. Important questions remain, however, about the definition of a high-risk population, cost-effectiveness of the scanning, and the problem of differentiating between tumors and growing granulomatous lesions, the editorial said.
Critics of the study noted the absence of placebo controls and the use of a statistical model, instead of hard data, to determine the 10-year survival rate, reported the Oct. 26 New York Times. A National Cancer Institute study that is currently underway will compare the effectiveness of chest X-rays to CT scans for nearly 55,000 current or former smokers, the Times said.
The New York Times is online.
In a new evaluation of evidence-based tools for point of care, ACP’s PIER was ranked #1 among the 14 resources reviewed. The study, titled "A Systematic Evaluation of Evidence Based Medicine Tools for Point-of-Care," was conducted by medical librarians from five libraries in Texas.
The librarians studied and conducted workshops on the tools, rating them on six main criteria:
- General information, including whether the product was truly point of care, the target audience and marketing claims;
- Content, including scope, patient handouts, CE credits and practice guidelines;
- Quality control, including authorship, updates and bias;
- Searching, both the types of search available and usability;
- Results, including presentation of results, evidence grading, evidence summary and references;
- Other features, such as customization, integration with other technologies, unique and useful features and coming features.
The evaluation was designed to help evidence-based medicine providers and researchers select the right tools from the current proliferation of products. PIER was selected as the top choice in every one of the evaluation’s raw and weighted rankings, which rated all major competitors.
The evaluation results are online.
In an Oct. 20 letter to Leslie Norwalk, JD, administrator for the CMS, ACP joined with other physician organizations to call attention to problems with Medicare’s consultation policy.
In the letter, the physician groups pointed to three main aspects of new clarifications that are contrary to the typical practice of medicine: transfer of care, documentation of consultations and billing for services performed by physicians and non-physician practitioners (NPPs). Changes to the consultation policy were published by CMS in December 2005.
The letter requested that CMS allow providers to bill for an initial consultation for a patient unless there is a complete transfer of care for the patient. The current policy is unclear on whether or not a physician may bill for an initial consultation if a portion of the care is transferred to the consultant.
The current policy also states that documentation of consult codes is needed in the patient’s medical records with both the referring and the consulting physician. The physician groups requested that the policy be changed so that, if all other requirements are met, the consulting physician is reimbursed whether or not the referring physician has made the appropriate documentation. They argued that the consulting physician should not be penalized for a referring physician’s failure to document a referral.
ACP and the other groups requested that the policy be changed to permit consultations shared by physicians and NPPs to be reimbursed at the level of payment used for physician services. With the delivery of many medical services, a team-based approach is often used in consultation and can lead to higher quality of care for the patient.
The full text of the letter is online.
As a benefit of membership, ACP members are eligible to receive a free copy of products developed by the Council of Young Physicians (CYP) for members’ reference and professional use, including the Young Physician Practice Management Survival Handbook and the Pocket Guide to Selected Preventive Services for Adults.
The Survival Handbook is a valuable resource for physicians who are just starting out and may not be sure how to proceed with the nuts and bolts of running and managing a practice: insurance, office technology, required licensing, staffing, billing and fee schedules, practice guidelines, management issues and more.
The Pocket Guide is a proactive way to encourage preventive care in your daily practice. The guide outlines selected screening services including those for asymptomatic bacteriuria, blood pressure and the abdominal aortic aneurysm. Also included are clinical guidelines and preventive measures with counseling approaches and adult immunizations.
The CYP was established in June 2005 by the ACP Board of Regents to enhance the professional development and quality of life for young physicians, foster their involvement in College activities, and ensure their needs are being met. Young physicians are defined as those who are within 16 years of graduating medical school and who are not Student or Associate Members.
More information is available online.
In the article, "Early Journal Club: Prompt revascularization improves survival after STEMI and cardiogenic shock, " in last week's edition, the mortality rates of the medical treatment and revascularization groups were inadvertently reversed. It should have stated that the three- and six-year mortality rates in the revascularization group were 59% and 67%, respectively, compared with 72% and 80% in the medical treatment group.
ACP Journal Club is online.
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Copyright 2006 by the American College of Physicians.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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